Heart, Lung and Circulation最新文献

Background: Medication-related problems (MRPs) are common during transitions of care for people with heart failure (HF), contributing to early hospital readmission and mortality. However, the integration of a nurse-pharmacist model of care (MoC) into transitional care has seldom been explored.

Aim: To determine the feasibility and acceptability of a nurse-pharmacist transition-of-care telehealth service for patients with HF discharged from the John Hunter Hospital, Australia. We also explored the impact of service provision on MRP detection, guideline-directed medical therapy (GDMT) prescribing, and hospital readmissions.

Method: Upon discharge, patients with HF were referred to an existing telehealth service and offered pharmacist-led medication reconciliation and education ("MedRec") in addition to usual care. Primary outcomes were feasibility, measured by recruitment and successful MedRec completion, and acceptability, measured by an investigator-developed survey. Secondary outcomes were MRPs detected during MedRec. Exploratory outcomes included GDMT prescribing and hospital readmission rates.

Results: A total of 100 patients with HF were offered MedRecs and accepted by 80 patients. In total, 62 MedRecs were performed, mean age 67.6 (±13.6) years, male sex (n=34/62; 54.8%). MRPs detected included: 25 recipients (40.3%) experiencing drug-related toxicity or adverse events, 13 recipients (20.9%) experiencing medication non-adherence issues, and 12 recipients (19.4%) with drug optimisation issues unrelated to their HF. Drug and/or disease management information was requested by 35 MedRec recipients (56.4%). Post-MedRec, 56.5% of participants completed surveys. Engagement with a pharmacist via MedRec enhanced medication education, was perceived to ease anxiety associated with understanding medication-related changes, and empowered greater self-management. GDMT optimisation was recommended for over two-thirds (69.2%) of MedRec conducted for HF with reduced ejection fraction patients. The rate of 30-day cardiovascular readmissions was reduced by nearly 8% for those who accepted a post-discharge MedRec compared to those who declined the MedRec service (8.1% (n=5/62) vs 15.8% (n=6/38) respectively, [p=0.324]).

Conclusions: A post-discharge nurse-pharmacist telehealth service is a feasible and well-accepted MoC. The inclusion of a routine MedRec post-discharge may enhance continuity of care, improve medication safety, and support HF management.

Background: Changes in cardiovascular health (CVH) in people with previous cardiovascular disease (CVD), including stroke or heart disease may reflect the success of secondary prevention strategies. This has not been examined among adult Australians over time.

Method: We included people aged >18 years from National Health Surveys (NHSs) in 2011-2012, 2014-2015, 2017-2018, and 2022 with a self-reported history of stroke or heart disease. At each time point, five items (smoking status, blood pressure [BP], body mass index [BMI], diet and physical activity [PA]) aligned with the American Heart Association's guidelines were scored as 0 "poor", 1 "intermediate", or 2 "ideal". An overall CVH score summing these items for each time point was grouped as poor (scores 0-4), intermediate (5-6), or ideal (7-10). We examined changes in the proportion of people with "ideal" or "intermediate" CVH score, compared to "poor" scores over time using multinomial logistic regression analyses reporting the risk ratio (RR 95% confidence interval [CI]) for years 2014-2015, 2017-2018, and 2022 compared to 2011-2012, adjusting for covariates (sex, age, socioeconomic status, marital status, education, and occupation).

Results: There were n=78,071 across the NHSs with 6%-7% (n=4,192) having a history of stroke or heart disease and included in the analysis. There was no change in the proportion with an "ideal" CVH score over the four surveys, but an increase in the likelihood of having an intermediate score, compared to a poor score in 2022, and compared to reference survey period (2011-2012) (RR_adjusted 1.38; 95% CI 1.06-1.81).

Conclusions: Ideal CVH prevalence remained and did not change significantly over time in people with a history of CVD. There is an urgent need for better secondary management efforts to manage risk factors and reduce recurrent CVD.

Aim: More older adults are living with an implantable cardioverter defibrillator (ICD). Deactivation rates for those approaching end-of-life are low, risking undue distress and an undignified death. This scoping review aimed to determine the availability and content of hospital guidance documents regarding ICD deactivation towards end-of-life.

Method: Guidelines' databases from two Australian states (Victoria and South Australia) were systematically searched between September 2022 to February 2023, to identify all documents that specified guidance for ICD deactivation at end-of-life. Relevant documents were analysed using a pre-specified data extraction tool.

Results: Following screening of 59,662 documents from 94 health services providing acute, aged or palliative care, 11 were included. Most were from public (10, 91%), metropolitan (eight, 73%) health services. Guidance on timing of ICD deactivation discussions was limited; only two (18%) documents advised discussion at time of insertion, one (9%) at generator change and six (55%) during advance care planning discussions. Recommended criteria for ICD deactivation varied: people with a terminal illness (two, 18%), with an active do not resuscitate order (five, 45%), receiving end-of-life care (11, 100%), or at the person's request (seven, 64%). Nine (82%) recommended consent dialogue that deactivation does not cause/hasten death (eight, 73%) or deactivate pacing (eight, 73%), aims to promote a peaceful death (eight, 73%) and that reactivation is possible (eight, 73%).

Conclusions: There is a paucity of local health service guidance to support clinicians navigating ICD deactivation at end-of-life.

Background: Transradial catheterisation is the default approach of coronary angiography, and the radial artery (RA) is a popular conduit choice for coronary artery bypass grafting (CABG). Whether a previously catheterised RA (CRA) remains an optimal bypass conduit for CABG is uncertain. This systematic review and meta-analysis sought to evaluate the previous CRA bypass graft patency.

Method: A systematic search is conducted in MEDLINE, Embase, and Scopus for comparative studies of CRA versus non-CRA (NCRA) grafts. The primary outcome of this study was RA graft patency. Random-effects models generated pooled effect sizes with heterogeneity assessed by I²; small-study effects were examined with funnel plot/Egger's test, and influence analyses were performed in the meta-analysis.

Results: Of the 1,661 studies screened, four observational studies of 400 patients (175 CRA and 379 NCRA grafts) were included in the analysis. Across the included studies, the mean time from catheterisation to CABG was 27.4±16.0 days; the mean follow-up imaging was conducted at 2.06±1.88 years. CRA graft patency was lower than NCRA (73.2% vs 83.9%), and the pooled odds of graft failure were higher with CRA (odds ratio 1.82; 95% confidence interval 1.26-2.61; p=0.001; I²=33%). There were no significant small-study biases detected on planned assessments.

Conclusions: Prior transradial catheterisation is associated with reduced patency of RA bypass grafts. Surgeons should exercise caution when selecting CRA for critical targets, and prospective controlled data are needed to define patient and procedural modifiers of risk.

Background & aim: Familial hypercholesterolaemia (FH) is a genetic condition that causes high plasma levels of low-density lipoprotein cholesterol, significantly increasing the risk of premature atherosclerotic cardiovascular disease. FH remains underdiagnosed and undertreated, despite the existence of high-level evidence and clinical practice guidelines. Both under-prescribing and non-adherence to medications have been identified as contributing factors. The aim of this study was to identify the barriers and facilitators or potential solutions to the implementation of improved FH management in Australia, focussed on primary care integration, paediatric management, and treatment adherence.

Method: Three (3) 2-hour virtual focus groups were conducted as part of the 2022 Australasian FH Summit (29 October 2022). A purposive cross-section of key stakeholder groups was sought at the Summit. The focus groups were co-facilitated by an implementation scientist and a clinician, audio recorded, transcribed, and notes were taken by the facilitators. Transcripts were analysed inductively and deductively according to a template analysis using NVivo.

Results: There was a total of 27 workshop attendees across the three groups (n=6-14 each). We identified 27 barriers and 28 facilitators on the topics of integration of care with general practice (nine barriers and eight facilitators), paediatric management (eight barriers and eight facilitators), and treatment adherence (10 barriers and 12 facilitators), categorised according to whether they were patient-related, provider-related, or system-related. Common barriers across the priority areas included a lack of knowledge and skills in FH and urgency of treatment, patient fears of actual or perceived side effects from medications and clinician confidence in prescribing, and costs to patients and limited funding for coordinated models of care. Common facilitators included engaging patients in self-management and in advocacy, developing pathways for care for different risk profiles and ensuring coordination of care between primary and tertiary care settings, and improving communication between clinicians.

Conclusions: These findings provide a foundation for the development of empirically-based implementation strategies tailored to the Australian healthcare context and highlight the importance of multi-level approaches to improving FH detection and management. Future work that is focussed on mapping strategies to these barriers and facilitators using implementation frameworks is needed to develop a national implementation plan for the integration of new guidance on the care of FH.

Background: Spontaneous coronary artery dissection (SCAD) is a cause of acute coronary syndrome linked with profound impact on mental health and health-related quality-of-life (HRQoL). This study aimed to explore the determinants of HRQoL for patients with SCAD.

Method: This is a multicentre, prospective cohort study in 23 hospitals across Australia and New Zealand. Patients aged ≥18 years diagnosed with SCAD confirmed on core laboratory adjudication were recruited and gave their informed consent. HRQoL was measured using the European Quality-of-Life 5 Dimensions (EQ-5D) questionnaire at 30 days after the index SCAD event. Beta-regression model was used to explore determinants of HRQoL.

Results: From 2021 to 2025, 193 people with confirmed SCAD were prospectively recruited, with mean age 52.7±10.7 years, 89.1% female, mean body mass index 28.2±6.2 kg/m², and 82.4% White. At least one cardiovascular risk factor was present in 50.8%, with hypertension the most common (30.1%). At a median of 33 days from the index SCAD event, the mean EQ-5D index summary score was 0.77±0.19 and the mean EQ-5D visual analogue scale score was 68.5±17.1. Overall, 43.0% had at least moderate pain/discomfort and 57.0% had at least moderate anxiety or depression. On multivariable analysis, fibromuscular dysplasia (FMD, coefficient -0.25; p=0.005), and female sex (coefficient -0.35; p=0.04) were independently associated with lower QoL scores.

Conclusions: SCAD has a significant impact on the HRQoL of survivors with high rates of pain, anxiety, and depression. Female sex and an FMD diagnosis were independent predictors of lower HRQoL. These findings support the need for FMD and mental health screening and support in SCAD survivors.

Aim: In exercise stress testing (EST), a discordant result with electrocardiogram (ECG)-positive and transthoracic echocardiogram (TTE)-negative is commonly encountered. This study aimed to determine the predictors of obstructive coronary artery disease (CAD) in patients with ECG positive, TTE negative ESTs.

Method: We performed a retrospective analysis of consecutive patients with discordant EST findings (ECG+ and TTE-) for ischaemia between November 2010 and June 2021. Key inclusion criteria were age >18 years and invasive or computed tomography coronary angiography within 12 months of EST. Patients with previous revascularisation were excluded.

Results: Of 115 patients, 72% (n=83) were male and mean age was 62 years. Overall, 85% (n=98) of patients had no obstructive CAD while 15% (n=17) had obstructive CAD. Baseline characteristics of the two groups were well-matched. There were no between-group differences in the resting ECG with respect to rhythm, ST-segment depression (STD) or left ventricular hypertrophy by voltage criteria. Patients with obstructive CAD were more likely to have STD of >3 mm (17.6 vs 3.1%; p=0.01). There was no difference between the groups for the duration of STD into recovery or for the presence of early versus late resolution of STD.

Conclusions: Our findings suggest that among patients with discordant (ECG+/TTE-) EST findings, peak STD >3 mm may correlate with the presence of obstructive CAD on angiographic evaluation. There was no association between the duration of STD and the presence of obstructive CAD.

Background: The ankle-brachial index (ABI) is the standard non-invasive diagnostic tool for peripheral artery disease, but it has some limitations, particularly in patients with arterial calcification. This study introduces the ankle-brachial humidity index as a novel diagnostic approach for peripheral artery disease.

Method: In this prospective single-centre study in Turkey, 100 patients underwent comprehensive cardiovascular assessment including ABI measurements, lower extremity arterial Doppler ultrasonography, and skin moisture measurements using a digital moisture device. The ankle-brachial humidity index was calculated using standardised measurements taken at the wrist and foot under controlled conditions. Peripheral artery disease diagnosis was confirmed using standard criteria (ABI ≤0.90 or significant stenosis on Doppler ultrasound).

Results: Of 100 patients, 33 were diagnosed with peripheral artery disease. Patients with peripheral artery disease showed significantly lower target leg humidity (median 14.3% vs 17.9%; p<0.001) and ankle-brachial humidity index values (median 0.75 vs 0.95; p<0.001) compared with patients without peripheral artery disease. The ankle-brachial humidity index emerged as an independent predictor of peripheral artery disease in logistic regression analysis (Odds ratio 0.598; 95% confidence interval 0.417-0.858; p=0.005). The ankle-brachial humidity index demonstrated significant correlations with established cardiovascular risk factors, including negative correlations with age (r=-0.235; p=0.001) and diabetes mellitus (r=-0.245; p<0.001).

Conclusions: The ankle-brachial humidity index represents a promising new diagnostic tool for peripheral artery disease that may complement existing methods, particularly in populations where traditional ABI measurements are less reliable.

Aim: This study aimed to describe and compare neonatal retrieval medical interventions among newborns with a postnatal vs antenatal diagnosis of critical congenital heart disease (CHD).

Method: The study design was a retrospective medical record review of infants aged ≤30 days admitted to The Royal Children's Hospital, Melbourne, Australia, with CHD from 2016 to 2020. Electronic data were collected, including demographic data, presenting signs, retrieval events, and mortality. Participants were separated into two groups for analysis: those with a postnatal diagnosis and those with an antenatal diagnosis of CHD.

Results: Of the 335 infants admitted with CHD, 30% had a postnatal diagnosis. Infants with a postnatal diagnosis had more resource-intensive retrievals requiring more respiratory support, supplemental oxygen, inhaled nitric oxide, and antibiotic administration. These infants also presented with higher numbers of respiratory and cardiovascular signs of illness at presentation. For infants with a postnatal diagnosis of critical CHD, the median age at symptom presentation and emergency retrieval was 26 and 91 hours, respectively. Four percent of infants died before 30 days of age.

Conclusions: Infants with a postnatal diagnosis of critical CHD present later, with more signs of illness, resulting in more resource-intensive emergency retrievals. A lower threshold for suspicion of CHD by referring paediatric clinicians in the newborn period may enable more timely transport of at-risk infants. This study has identified potential areas for future research aimed at expediting cardiac diagnosis at the time of illness presentation.